Understanding Medical Terms

Over recent years, more and more patients have gained online access to their electronic medical records. But those reports may be difficult to understand even for highly literate persons. Some doctors are still writing or dictating reports containing medical terminology, abbreviations, and jargon that thwart understanding. Here’s a road map to help you steer through the challenging language.

Decoding ‘doctor-speak’

The history and physical (H&P) portion of your medical records is a write-up of the information your doctor gets by asking you about your medical history and performing a physical exam. You might encounter some of the following abbreviations he or she noted on your record:

DOE: dyspnea on exertion (shortness of breath during activity)

GI: gastrointestinal (digestive system)

GU: genitourinary (the reproductive and urinary systems)

HEENT: head, eye, ear, nose, and throat

HPI: history of present illness (the background of your current health concerns)

HR: heart rate

NKA: no known allergies

NKDA: no known drug allergies

NVD: nausea, vomiting, and diarrhea

R/O: rule out

ROM: range of motion

SOB: shortness of breath

WNL: within normal limits

Don’t take it the wrong way

Watch out for terms that sound judgmental but aren’t meant to be: A patient’s “complaint” refers to the health concern that brought him or her to the clinician. A patient who “denies” a fever isn’t aware of having one. When a patient “fails” a treatment, it doesn’t mean the patient is at fault; it means the treatment was ineffective. “Gross,” when used as a medical term, describes something that can be seen by the naked eye (as opposed to needing a microscope to see something).

Your X’s explained

You likely know that Rx refers to a medical prescription, but what about all the similar shortcuts you may find in your records?

Bx: biopsy

Dx: diagnosis

Fx: fracture

Hx: history

Px: prognosis

Sx: symptoms, signs

Tx: therapy, treatment

Lab test lingo

Your patient portal will typically include a section for lab tests—the results of blood tests, urine tests, and the like. Some lab tests measure levels of a chemical or a substance, with results given in standard units—like g/dL (grams per deciliter) or mmol/L (millimoles per liter). The lab report may indicate whether those values are within a normal, or “reference,” range. Other lab tests measure, or detect the presence or absence of, certain substances. A positive result indicates the substance or condition being tested for was found; a negative result means it wasn’t.